Eat and Run

Why we’re so fat.

On January 20, 2003, the English journalist William Leith decides he has to lose weight. That’s the day he gets on the bathroom scale and finds that it’s “the fattest day of my life”: he’s just over six feet tall and he weighs two hundred and thirty-six pounds. He feels lousy. He feels repulsive. In fact, he is repulsive. His girlfriend tells him to stop tucking his shirt into his trousers—“It just bulks you out”—and she doesn’t want to have sex with him anymore. He resolves, not for the first time, to do something about it. He gets on a plane and goes to New York to see Dr. Atkins, and he decides, more or less at the same time, to write a book about his eating problems. “The Hungry Years: Confessions of a Food Addict” (Gotham; $25) is the result: Bridget Jones with a Y chromosome, a significant coke habit, and a sneaky sort of intellectual ambition.

Leith’s book is about food addiction, but he’s interested in all sorts of addictions and what it is about our culture that makes it so easy to stuff ourselves, leaving us filled but unfulfilled: “This is the fat society. This is where people come, so they can have exactly what they want. And what they want is . . . more.” Most of all, he’s interested in himself. If he can figure out why he’s a food addict, then maybe he can figure out why he’s unhappy: “I am fat because I have other, deeper problems.” And if he can figure out what these deeper problems are then maybe he can stop stuffing himself. The cure has two courses. The physical bit is getting the weight off; the psychological bit is getting the weight off his mind. Dr. Atkins takes care of the first. Leith arrives at Atkins’s Manhattan clinic just months before the great man’s death, and about two years before the “low-carb craze” will itself be pronounced dead, with the venture-capital-crammed Atkins Nutritional, Inc., going into bankruptcy. But Atkins is then enjoying a boom: some months before, Gary Taubes published a pro-Atkins polemic in the Times Magazine (“What If It’s All Been a Big, Fat Lie?”), and a copy of New York that Leith picks up declares, “Welcome to a City in the Throes of CARB PANIC.” Leith masters the Atkins metabolic mantra: carbohydrates cause a rush of insulin; the insulin reduces blood glucose, causing cravings for more carbs; the body becomes insulin-resistant; and it shifts its attention to saving fat. Food fat doesn’t make your body fat; carbs are the culprit. As the pounds fall off—thirty in four months—Leith becomes an evangelist: his obituary of Atkins in the Guardian of April 19, 2003, is a panegyric. He reads Thomas Kuhn’s historical theory of scientific development and decides that Atkins is achieving nothing less than a dietary “paradigm change.” Atkins is a hero of our time.

The other part of the cure is psychotherapy. The Atkins diet is the instrumental arm of a psychodynamic search: it’s good to lose weight in the most effective way you can, but Leith still feels the need to sort out the psychic reasons that he’s become a fatty. There’s much recollecting of childhood traumas; original sin for Leith was not an apple but an apple pie—one of his grandmother’s that he secretly gobbled down at the age of seven. By the end of his therapy, Leith has concluded that there are “many many reasons” for his food addiction. It’s too complex for him to understand and, perhaps, too complex for any specific diet to remedy or therapy to analyze. As the Atkins diet works its wonders, he feels happier: he gets fit, and he even goes for a twenty-five-mile hike with his (new?) girlfriend, at the end of which they pop into a pub and tuck in like ordinary human beings—“spaghetti with a meat sauce, and some garlic bread, and a bottle of wine.” He’s genuinely hungry for the first time in ages. As the proverb has it, hunger turns out to be the best sauce. He winds up—like the growing number of Atkins dieters who have fallen away from the faith—edgily wondering if moderation in all things might, after all, be the answer.

Leith wants to lose weight because he wants not to be repulsive, and he’s not alone. A fifth of American men and more than a third of American women say they would like to lose at least twenty pounds, and you don’t need a statistical survey to establish that sexual appeal is a big part of the reason. Thundering denunciations of the equation between female thinness and sexiness have little effect. The world is unfair that way—possibly almost as unfair to fat men as to fat women. In Paddy Chayefsky’s 1955 play “Marty,” the title character whines, “I’m just a fat little man. A fat ugly man.” Moreover, statistics do establish that fat people earn less: possibly because the sort of people who make less money tend to be fat, possibly because fat people are discriminated against, or, most likely, a bit of both.

It was not always so. When the Duchess of Windsor pronounced that “you can never be too rich or too thin,” it was a sign of a demographic shift with far-reaching cultural consequences. The language that our ancestors used to assess people’s weight generally had a qualitative and whole-body character: “thin,” “gaunt,” “lean,” “lanky,” “stout,” “fleshy,” “corpulent,” “beefy,” “plump,” “portly,” and, finally, “fat.” With some exceptions, it was good to be fat: in the Oxford English Dictionary, one definition of the adjective is “in well-fed condition, plump,” and in its figurative usages it signalled an abundance of good things—“the fat of the land,” a “fat living” for a cleric. In 1825, the French gourmand Brillat-Savarin wrote that “to acquire a perfect degree of plumpness . . . is the life study of every woman in the world.” Male or female, body fat showed you were a considerable person, that you commanded resources. Holbein’s great portrait of Henry VIII depicts not an obese man but a Big Man. And fat John Falstaff was, in his own estimation, “a goodly portly man, i’faith, and a corpulent, of a cheerful look, a pleasing eye, and a most noble carriage.” In societies marked by dietary scarcity—which is to say in practically any period before the twentieth century and in practically any present-day country outside the developed world—bodily bulk functions as a visible mark of power, affluence, and even good humor. In the late Middle Ages, the starving masses fantasized about the Land of Cockaigne, where you could idly gorge yourself on cakes and cream, and the American hobo anthem “Big Rock Candy Mountain” was a version of the same never-satisfied dream of abundance: “There’s a lake of stew / And of whiskey too / And you can paddle / All around it in a big canoe.” It’s hard to avoid the conclusion that fat became ugly when the poor became fat.

But being fat isn’t just an aesthetic bane; it’s understood to be a medical one as well. And this, too, is a historically recent development. When Prince Hal dismissed Falstaff by telling him that “the grave doth gape for thee thrice wider than for other men,” he meant to make a joke, not to offer a summary of epidemiological evidence. Writers from the Renaissance through the nineteenth century were, of course, aware that health risks might attend the very fat. Even Brillat-Savarin, for whom obesity was essentially a moral, mechanical, and social problem, not a medical one, noted that extreme obesity “opens the way for various diseases, such as apoplexy, dropsy, and ulcers of the legs, and makes all other ailments more difficult to cure.” Yet our ancestors certainly did not recognize a linear relation between increasing weight and health risk, and an over-all association between the gluttonously fat and a shortened life span was sometimes even denied, as when Francis Bacon judged that “the greatest gluttons are often found the most long-lived.” Whatever objections the early moderns had to corpulence were as much moral as they were strictly medical. People who gorged themselves gave a visible sign of poor self-control; what mattered was their flawed character, not their mortality risk. Gluttony was a vice before obesity was a disease.

And not just any disease. According to the Centers for Disease Control, which is the federal government’s official voice on public health, being overweight or obese “increases the risk of many diseases and health conditions,” including type-2 diabetes, osteoarthritis, heart disease, stroke, and certain cancers, notably of the breast, colon, and endometrium. The World Heart Federation has just warned that being overweight or obese “can advance a first heart attack by four to eight years.” To the extent that there is an official consensus on such things, this is it: if you’re overweight or obese, you’re running a substantial risk of ill health and premature death; if you want to avoid these evils, lose weight.

The phrase “obesity epidemic” expresses the sense that obesity not only is a disease itself but gives rise to a wide range of other diseases; it also reflects the indisputable evidence of fat’s growing prevalence. About two-thirds of American adults can be officially classified as “overweight,” and more than a quarter are “obese.” The C.D.C. sees the epidemic as sweeping the country state by state: the “fattest” states make an arc that runs from Texas through Louisiana, Mississippi, and Alabama to West Virginia, with obesity rates greater than twenty-five per cent; the “thinnest” include Massachusetts, Vermont, Rhode Island, and Connecticut, with rates below nineteen per cent. (Prudently, the C.D.C. draws no political conclusions, though its vivid map of our burgeoning national bulk colors the fat states red and the thin ones blue.) Averages can also be broken down by gender, ethnicity, education, and income level. Since 1970, according to one source, the average American man has gained seven pounds and the average American woman thirteen. However, there’s a lot of lumpiness hidden in these statistics. Some groups of individuals, such as the Pima Indians, of southern Arizona, are getting much fatter than other groups, such as white professional men with advanced degrees and personal trainers. It’s been some time since the average capitalist fat cat was actually fat.

What counts as overweight? In the United States, as in other countries, the body mass index is the officially approved way of deciding whether or not you’re too heavy. Leith, who curiously makes no mention of the medical issues associated with obesity, never seems to have worked out his own B.M.I. Had he done so, the answer would have been 32. (To calculate your B.M.I., divide your weight in pounds by the square of your height in inches, and then multiply the result by 703.) The C.D.C. tells you that a B.M.I. over 30 means you’re “obese,” while values between 25 and 29.9 mean you’re “overweight.” Still, the B.M.I. net catches some surprising fish. At six-six and a playing weight of two hundred and sixteen pounds, Michael Jordan was “overweight” (with a B.M.I. of 25); and, on the Boston Red Sox, Manny Ramirez and David (Big Papi) Ortiz are “overweight” (27.1 and 28, respectively), while the pitcher David Wells is “obese” (31.2), though that won’t come as a shock to Red Sox Nation. (Yankees fans should not feel too smug: both Jaret Wright and Hideki Matsui, at 29.5, are a Fenway Frank short of obesity.) The B.M.I. doesn’t tell you the percentage of body fat you’re carrying or how your fat is distributed, and it hasn’t got much to do with how you feel or whether you’re repulsive to potential sex partners. What it’s meant to do is provide a rough-and-ready index of a population’s health risks.

Precisely what those are, however, is less settled than it appears. Dr. Julie Gerberding, the head of the C.D.C., was one of the authors of a paper that was published, in March of 2004, in the distinguished Journal of the American Medical Association warning that obesity was responsible for killing four hundred thousand Americans a year—almost as many as tobacco. Some obesity treatments are now tax deductible as medical expenses, and some are reimbursable by health insurers. Three-quarters of Americans apparently see obesity as an “extremely” or “very” serious public-health problem, and the avoidance of premature death is a major reason that Americans seek to lose weight. J. Eric Oliver, a Chicago political scientist and obesity researcher, finds this whole state of affairs remarkable. His “Fat Politics: The Real Story Behind America’s Obesity Epidemic” (Oxford; $26) is an extended polemic against the causal association of overweight and ill health. He finds no reason to believe the usual assertion about the health effects of the “obesity epidemic”—that two-thirds of Americans weigh “too much,” that hundreds of thousands of us are dying each year from fat, that obesity costs hundreds of billions of dollars in health-care expenditures—and, though he’s not an epidemiologist, he stitches together a patchwork of epidemiological evidence to make his case.

Epidemiologists don’t even agree on whether overweight people who manage to lose weight improve their health. As one group of C.D.C. researchers put it, “Evidence that weight loss improves survival is limited.” We are getting fat, but, Oliver says, we’re not getting sick because of it. Excess body fat, and its effects on your joints, can contribute to osteoarthritis, Oliver concedes, and he grants that there is a decent causal story about cancer of the uterus and the higher estrogen levels found in overweight women, but that’s about it. A high B.M.I., in Oliver’s opinion, is most likely a proxy for things that are the direct causes of both obesity and disease, such as poor diet and lack of exercise. If you have a high B.M.I. and you’re fit, Oliver thinks that there’s no evidence that you’re more likely to suffer ill health than anyone else. Fat people are not usually fit, and they often eat foods rich in saturated fats, sugar, and refined carbohydrates, but it’s the lack of exercise and a poor diet that make for bad health, not “excessive” weight. Oliver discusses a number of studies purporting to show that weight loss is responsible for remediating a range of illnesses. However, epidemiologists are too quick to ascribe to weight loss what might be better attributed to the life-style changes that produce weight loss. This, Oliver claims, “is like saying ‘whiter teeth produced by the elimination of smoking reduces the incidence of lung cancer.’ ”

As it happens, a little more than a year after Julie Gerberding’s report appeared in JAMA one of her employees, Katherine Flegal, published a paper in the same journal which came to strikingly different conclusions. Flegal argued that obesity’s body count was far lower than Gerberding estimated; most of those deaths were among the small number of the very obese (B.M.I. greater than 35); people in certain age groups who were by C.D.C. criteria overweight but not obese had a lowered risk of death compared with those who were “normal”; and being underweight killed about thirty-four thousand Americans a year. The Times announced the good news on the front page: “SOME EXTRA HEFT MAY BE HELPFUL.” A number of epidemiologists and nutrition researchers welcomed Flegal’s paper. Obesity “is presented as a crisis and it’s presented as this horrible problem which has exploded onto the scene,” one expert said. “What this paper shows is that it’s just not true.” Not surprisingly, Flegal’s research was also met by heavy counterattacks, and the argument continues.

We can believe the dissenters or not—the way things are going, we probably won’t—but on several points Oliver’s is a valuable voice: obesity is an extremely complex phenomenon; inference from the population to the individual is always highly problematic; no one knows what course of behavior is certain to be good for you; some “cures”—bariatric surgery and the Atkins diet among them—may turn out to be more dangerous than the condition they seek to remedy; nutrition scientists and epidemiologists routinely contradict each other on matters of public policy and in the advice they give to individuals. The problem for the concerned but disinterested observer is not that there is no certainty in these matters; it’s that there are too many certainties. A diet slightly richer in humble pie might do nutrition experts some good.

For a skeptic like Oliver, the question is why, given the state of the evidence, we live in fear of an “obesity epidemic.” Why do so many of us want so urgently to lose weight? One answer he offers is that we’re largely ignorant about the endemic uncertainties and the disagreement among experts in this area. Another is that we have an irrational revulsion toward obese people. What he calls—God help us—“fatism” is a way of smuggling in prejudice against women and racial minorities. Significantly more African-Americans and Latinos are obese than non-Latino whites. Oliver generated computer images of men and women and noted that observers judged women to be “fat” at relatively lower body weights than men. He claims that seventy per cent of all Americans—and almost that many physicians—think that laziness and poor self-control are the predominant causes of obesity, and so obesity can be a vehicle for our moral prejudices.

Having told us that our attitudes toward obesity are irrational, Oliver thinks we should just give them up and move on. But that’s like fat William Leith telling the girlfriend who doesn’t want to have sex with him anymore that she’s being irrational. Maybe it should work, but it never does. The “soft” cultural, social, and moral facts of the matter about obesity turn out to be harder to shift than beliefs about the relevant scientific facts. Fat was once considered a sign of substance and now it isn’t. It was once thought sexy and now it’s the opposite. Historical and cultural variability in such things are also facts of the matter, but we’re snagged in the ropes of our own culture, and to be told that things once were, and ought to be, otherwise is of little help to fat people living in the here and now.

So even if you accept Oliver’s account of the evidence, you may still want to lose weight, and those who are interested in the psychic as well as the bodily health of contemporary American society may still want to understand why we’ve grown so fat. Maybe, after all, we can do something about it; and maybe, if we can’t, we can understand why not and so save ourselves the money and the worry. Here Oliver joins other obesity researchers in having one really good idea: the key to the spread of obesity in America is technology-produced abundance. There are a lot of calories around; they’re cheaper than they ever were; and they’re more accessible as we move about in the course of a day. Our genetic constitution, having evolved in scarcity, was designed to store up as much fatty tissue as possible in rare periods of plenty, and, since we now live in permanent glut, nature has programmed us for obesity, some of us more than others. The Land of Cockaigne is a nice place to visit; the trouble is that we’re stuck living there.

As the economist David Cutler and his colleagues have shown, since the mid-nineteen-seventies the average American’s calorie intake has increased by about ten per cent and American food production per capita has increased by twenty per cent. Some commentators also blame lack of exercise, and our working lives have indeed become more sedentary, but we wind up running around more, and Cutler isn’t convinced by the evidence that our over-all levels of exercise have declined. Others blame burgeoning portion size for obesity, but Cutler disputes that, too. It’s not that we’re eating more at meals; it’s that we’re eating more often and what we’re eating is often calorie rich. We don’t eat meals; we snack, graze, and nosh. We’ve become an eat-on-the-run, absent-mindedly feeding, cup-holder culture. Technology has made calories bountiful, cheap, and easy to consume, while new patterns of work, residence, mobility, and child rearing have squeezed the time that we are able or willing to commit to family or communal meals.

In the early-modern period, books of manners recommended that a gentleman always eat in company. King James I warned his son never to eat alone, lest people think it was for the “private satisfying of your gluttonie, which ye would be ashamed should be publicklie seene.” The social setting was understood to set moral limits on consumption. The shared meal marked the beginning and the end of eating: there was a time to eat and a time to stop. The meal defined the when, the what, the how, the how long, and the how much. You adjusted your consumption to those who were eating with you. You didn’t have exactly what you wanted, exactly when you wanted it, and exactly as much as you might want. The marking, ordering, and, above all, limiting character of the shared meal remained largely intact into the twentieth century: Leith’s grandmother used to warn him about appearing “greedy” at the table, and, while my own grandmother absolutely required that we have “seconds,” it was not a great idea to be seen eating when she wasn’t feeding you. Sometime in the postwar era, though, the domestic meal began its unremitting decline. Now, like many of us, Leith mostly eats standing up—no grandmother, no mother, often no one at all to witness “greed.” The individualization of eating has done much to cut us free of dietary limits. We’ve been told that an index of our times is that we “bowl alone”; something similar might be said of our gastronomic habits. We eat alone and we get fat together.

The feast, in times past, was a meal set off from the ordinary by its abundance and richness. Our feasts have now become as ordinary as they are mobile. It’s a little more than a mile from my house, in Central Square, in Cambridge, up Massachusetts Avenue to Harvard Yard. As I walk to work I pass forty establishments where I can get fed (only five of which happen to be franchised fast food). There are five all-you-can-eat buffets (three Indian, one Chinese, and one Tibetan), and fifteen places where high-fat, high-sugar drinks and finger foods are visible from the sidewalk or available within several steps of the entrance. Many of the people I pass are eating or drinking as they walk, and others are doing the same alone in their cars. When I get to the building where I work, I pass, on the way to my office, a cafeteria whose display features an assortment of doughnuts, brownies, croissants, and pastries. It looks pretty good today, so I pick up a prune Danish. ♦